Interstitial lung disease

Question 1

What are causes of transudate?

Answer 1

heart failure
cirrhosis
hypoalbuminaemia
atelectasis
nephrotic syndrome
constrictive pericarditis
Meigs syndrome

Question 2

what are causes of haemothorax? treatment?

Answer 2

usually traumatic or iatrogenic

may need chest drain or surgical drainage

Question 3

what are causes of exudate?

Answer 3

infection (simple / complicated ‘parapneumonic’ effusion), TB
malignancy, RA
pulmonary embolism, asbestos related, pancreatitis

Question 4

what is chylothorax?

Answer 4

a type of pleural effusion. It results from lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct

Question 5

what does chylothorax look like (effusion)? causes?

Answer 5

milky appearance

lymphatic interruption
lymphoma, iatrogenic

Question 6

causes of empyema?

Answer 6

CT/USS septations
may or may not be ‘unwell’
inflammatory markers may/not be raised
risk factors: alcoholism, immunocompromised
treatment: antibiotics +/- drainage (surgical / chest drain)

Question 7

empyema pH & glucose?

Answer 7

pH <7.2

glucose <3.4mmol

Question 8

pleural malignancy - common metastases?

Answer 8

lung, breast

Question 9

primary pleural malignancy? cause?

Answer 9

mesothelioma

asbestos exposure

Question 10

primary pleural malignancy x-ray appearance?

Answer 10

effusion, mediastinal pleural enhancement

Question 11

how are the types of pneumothorax classified by causes?

Answer 11

primary - otherwise healthy people
secondary - underlying lung disease e.g. cancer, COPD
iatrogenic pneumothorax - procedures e.g. central lines

Question 12

what are facts about primary spontaneous pneumothorax?

Answer 12

smoking is important
lifetime risk higher in smokers (12% compared to 0.1%)
once you’ve had pneumothorax, at higher risk of developing another
risk of recurrence is 54% within first 4 years

Question 13

symptoms of pneumothorax?

Answer 13

pleuritic chest pain

dyspnoea

Question 14

investigations for pneumothorax?

Answer 14

plain CXR

Question 15

what is a small and large pneumothorax?

Answer 15

small: <2cm
large: > or equal 2cm, between lung margin & chest wall

Question 16

pneumothorax treatment?

Answer 16

observation (without significant SoB)

no SoB, pt discharge with small primary pneumothorax (<2cm)

Question 17

if a pt is admitted for overnight observation with pneumothorax, then what should be given?

Answer 17

high flow oxygen should be given (10L/min)

Question 18

patients with pneumothorax and SoB should have what?

Answer 18

intervention regardless of size of pneumothorax

Question 19

what is first line treatment for all primary pneumothoraces requiring intervention?

Answer 19

simple aspiration

Question 20

when is simple aspiration less likely to succeed?

Answer 20

in secondary pneumothoraces
only recommended as initial treatment in small (<2cm)
pneumothoraces in minimally breathless patients under age of 50

Question 21

what should you do to patients with secondary pneumothoraces treated successfully with simple aspiraiton?

Answer 21

admit patients with secondary pneumothoraces treated successfully with simple aspiration & observe for at least 24 hours before discharge

Question 22

what should you do if simple aspiration or catheter aspiration drainage of any pneumothorax fails to control symptoms?

Answer 22

insert an intercostal tube

Question 23

when is intercostal tube drainage recommended?

Answer 23

in secondary pneumothorax

Question 24

when is intercostal tube drainage NOT recommended in secondary pneumothorax?

Answer 24

in patients not breathless with a very small (<1cm or apical) pneumothorax

Question 25

when is it necessary to replace a small chest tube with a larger one in chest drain in secondary pneumothorax?

Answer 25

if persistent air leak

Question 26

what are other treatments of pneumothorax?

Answer 26

chemical pleurodesis
open thoracotomy & pleurectomy (lowest recurrent rate)
minimally invasive procedures: thoracoscopy (VATS), pleural abrasion, surgical talc pleurodesis - all effective

Question 27

when is chemical pleurodesis used?

Answer 27

to control difficult or recurrent pneumothorax

Question 28

when should chemical pleurodesis be attempted?

Answer 28

only if the patient is unwilling or unable to undergo surgery

Question 29

how is tension pneumothorax diagnosed?

Answer 29

clinically, NOT radiologically

index of suspicion

Question 30

what are signs of tension pneumothorax?

Answer 30

cardiovascular compromise - tachycardia, hypotension
decrease expansion with hyper resonance & absent breath sound on side of pneumothorax - death
shift of mediastinum to opposite side - trachea, apex beat
hypoxaemia

Question 31

what is treatment for tension pneumothorax?

Answer 31

DON'T wait for CXR
cannula into affected side
oxygen
intercostal chest drain
respiratory / thoracic surgical referral - DON't want recurrence
surgical pleurodesis

Question 32

warnings to patients post discharge with pneumothorax

Answer 32

don’t fly until 1 week after CXR confirmed resolution (patients discharged without intervention)
permanently avoid diving

Question 33

what should secondary pneumothorax patients successfully treated with aspiration do before discharge?

Answer 33

be admitted for 24 hours before discharge